Medical management using 600 microg misoprostol vaginally is more effective than expectant management of early pregnancy failure. Misoprostol did not increase the side-effect profile and patient acceptability was superior to expectant management.

severe intrauterine growth retardation. There were no differences even in the number of induced deliveries, let alone caesarean sections between the aspirin and the placebo groups. The mean gestational age and birthweight at delivery were over 39 weeks and greater than 3500 g in the placebo group. The number of babies with birthweight less than 2500 g were 3/43 and 4/43 in the aspirin and placebo groups, respectively. The authors do not report on the severity of hypertension in terms of how many women in each group required de novo anti-hypertensive medication in pregnancy (or an increase in pre-existing medication), nor do they report on the need for closer maternofetal monitoring or hospital admission. The study shows differences that are statistically significant and academically interesting, but which do not appear to be quite clinically relevant, a picture very similar to that shown in the study by Chappell et al. 1 , which extolled the benefits of anti-oxidant supplementation (vitamins C and E) in the reduction of the incidence of pre-eclampsia in a high risk population. Appropriately, Vainio et al. suggest that a larger, probably multicentre, trial would be required to assess the effect of aspirin on early-onset pre-eclampsia and intrauterine growth retardation, but the virtual absence of trends with regard to these endpoints in this study leaves room for scepticism. It would appear that aspirin, and perhaps vitamins, can modify the clinical course of hypertensive disease and pre-eclampsia in pregnancy slightly, but it is premature to suggest that they are effective in reducing significantly the important causes of maternal and fetal morbidity and mortality. Reference 1. Chappell LC, Seed PT, Briley AL, et al. Effects of anti oxidants in the occurrence of pre-eclampsia in women at increased risk: a randomised trial. Lancet 1999:354:810-816. John H. Smith St Mary's NHS Trust, London PII: S 1 4 7 0-0 3 2 8 (0 2) 0 2 8 0 9-4 Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms? Sir, I read the article by Robinson et al. 1 with interest. The authors should be congratulated in completing this study on a substantial sample of women. However, I would be grateful if one or two points in the results and the statistical analysis could be clarified. The important question is whether ultrasound measurements of bladder wall thickness can be adequately diagnostic. Central to this is: How much do these thickness measurements overlap between groups diagnosed urodynamically? The authors give results including those below, and conclude that 'Examination of the 95% CIs reveals no overlap in those women with a diagnosis of detrusor instability and in those with a diagnosis of GSI': This appears to be a non-sequitur. It is perfectly possible to have different means with non-overlapping confidence intervals, but still have so much overlap between the groups that many individual measurements will not be diagnostic. It is essential to distinguish between the 95% CI and the sprea...

To our knowledge this is the first study to show the cellular localization of muscarinic receptor subtypes 2 and 3 in the human bladder. The increase in muscarinic receptor subtypes 2 and 3 immunostaining in myofibroblast-like cells in clinical bladder syndromes and its correlation with clinical scores suggests a potential role in pathophysiological mechanisms and the therapeutic effect of anti-muscarinic agents.

Multiple methodologies provide strong justification for the recommendation of a 10-point minimally important difference for all overactive bladder questionnaire subscales. This minimally important difference may be conservative for some subscales, although a uniform minimally important difference is recommended to facilitate interpretation of the overactive bladder questionnaire.

A new technique of measuring bladder wall thickness using transvaginal ultrasound is described. Measurement of the bladder wall using ultrasound was found to have a good intra- and interobserver reproducibility. Measurements of the bladder wall thickness were altered if more than 50 ml of fluid was within the bladder. Forty-five women with urinary symptoms were recruited from the urodynamic clinic; those with urodynamically diagnosed detrusor instability were found to have significantly thicker bladder walls than women with urodynamically diagnosed genuine stress incontinence. Application of this technique may be useful in the diagnosis of detrusor instability.

Objective To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies. Design A blinded prospective study.Setting Tertiary referral unit in a London teaching hospital.Population One hundred and twenty-eight women referred for ambulatory urodynamics with equivocal laboratory urodynamic findings or whose symptoms were not explained by the laboratory urodynamic findings. Methods Transvaginal ultrasound assessment of bladder wall thickness was performed in three planes with an empty bladder prior to ambulatory urodynamics. Mean bladder wall thickness was calculated and the results analysed with respect to the ambulatory urodynamic diagnosis. Main outcome methods Mean bladder wall thickness in women with a normal ambulatory study or a diagnosis of detrusor instability, genuine stress incontinence (GSI) or mixed incontinence. Results Using a one way analysis of variance (ANOVA) bladder wall thickness was found to be significantly different in all diagnostic groups and this reached significance ( P ¼ 0.0001). There was no overlap in the 95% confidence intervals representing a diagnosis of detrusor instability or genuine stress incontinence. Conclusions Transvaginal ultrasound assessment of mean bladder wall thickness is a sensitive screening tool, which can detect detrusor instability in those women with equivocal laboratory urodynamics. In women who have no evidence of GSI on laboratory studies, a cutoff of 6.0mm is highly suggestive of detrusor instability. However, in those women with GSI then ambulatory studies probably remain the investigation of choice.

Ultrasound vaginal wall thickness demonstrated good intra- and interoperator reliability, as well as consistency with histological measurement. It is a valid technique.

The conventional management of irritative bladder symptoms, namely urgency, urge incontinence, frequency and nocturia, with anticholinergic medication is limited by the side effects of treatment. Acupuncture is shown to be as effective in the management of irritative bladder symptoms as conventional anticholinergic therapy, with few side effects and a high degree of patient acceptability and compliance.